The nurse is continuing to assist with the care of the client.
The nurse is assisting with initiating the client's plan of care. Which of the following interventions should the nurse include? Select all that apply.
Administer betamethasone.
Monitor intake and output every hour.
Assist RN with performing a vaginal examination every 12 hr.
Obtain a 24-hr urine specimen.
Provide a low-stimulation environment.
Give antihypertensive medication.
Maintain bedrest.
Correct Answer : A,B,D,E,F,G
- Administer betamethasone: Betamethasone is administered to pregnant clients at risk of preterm delivery to promote fetal lung maturity. Given the client's gestational age of 31 weeks and signs of severe preeclampsia, administering corticosteroids is critical to prepare for potential early delivery.
- Monitor intake and output every hour: Severe preeclampsia can impair renal function, leading to decreased urine output and worsening fluid retention. Hourly monitoring of intake and output helps detect early signs of renal compromise and fluid overload, both of which require immediate intervention.
- Assist RN with performing a vaginal examination every 12 hr: Vaginal examinations are avoided in cases of severe preeclampsia unless absolutely necessary because they can stimulate uterine contractions or introduce infection. Therefore, routinely assisting every 12 hours with vaginal exams is not appropriate in this client's plan of care.
- Obtain a 24-hr urine specimen: A 24-hour urine collection assesses the degree of proteinuria and provides a clearer diagnostic picture of the severity of preeclampsia. Quantifying protein excretion helps guide clinical management and decisions about timing of delivery.
- Provide a low-stimulation environment: A calm, quiet environment minimizes the risk of seizure activity in clients with severe preeclampsia. Reducing auditory, visual, and environmental stimulation is a standard preventative measure to decrease neurological irritability.
- Give antihypertensive medication: Severe hypertension must be promptly treated to prevent complications like stroke, placental abruption, and progression to eclampsia. Administering antihypertensive therapy helps stabilize maternal blood pressure and protects both maternal and fetal health.
- Maintain bedrest: Bedrest helps reduce blood pressure and physical stress, promoting better perfusion to the placenta. Although strict bedrest is controversial long-term, short-term bedrest is often used in severe preeclampsia management while stabilization measures are implemented.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
A. Plan time at the end of the shift to document nursing interventions: Waiting until the end of the shift to document can lead to inaccuracies and missed details. It is more effective to document in real-time or immediately after providing care to ensure complete, accurate, and timely records, reducing errors and memory lapses.
B. Keep track of how long it takes to complete certain tasks: Monitoring how long tasks take helps the nurse better allocate time and identify where delays occur. This awareness allows for improved scheduling, more accurate prioritization, and realistic planning during the shift, leading to better time management.
C. Delegate collection of vital signs to the assistive personnel on the team: Delegating appropriate tasks, like vital signs collection, frees the nurse to focus on critical thinking, assessments, and interventions that require professional judgment. Proper delegation is an essential time-management strategy in providing efficient and safe client care.
D. Complete activities with one client before moving to another client: While thoroughness is important, it is not always efficient to rigidly finish all activities with one client before seeing others. Time-sensitive or urgent tasks with other clients may require interruptions, and flexibility is crucial for safe, effective care management.
E. Make a priority to do it at the beginning of the shift: Establishing priorities at the beginning of the shift ensures that essential and urgent needs are addressed promptly. Early planning helps organize tasks efficiently, reduces chaos during busy periods, and helps maintain focus throughout the shift.
Correct Answer is B
Explanation
A: Image A shows a newborn wrapped in a blanket with generalized redness on the face but without distinct blotchy areas or pustules. This appearance is more consistent with normal transitional skin changes such as acrocyanosis or overall mild skin redness after birth. It does not match the appearance of erythema toxicum.
B: Image B shows a close-up of the newborn’s face with visible small red blotchy spots, especially around the cheeks and nose. This matches the classic presentation of erythema toxicum, a benign newborn rash appearing within the first 24 hours. It is characterized by red patches with possible small pustules scattered over the face and body.
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